The problem of pain: Additive analgesic effect of tramadol and buprenorphine in a patient with opioid use disorder

Abstract

Background: There is a paucity of published literature on the optimal treatment of pain in patients on buprenorphine treatment (BT) for opioid use disorder. Using this case report, we hope to demonstrate that tramadol may represent an effective treatment option for pain in patients on BT while encouraging future clinical trials. Case: The patient is a 56-year-old Caucasian male with a history of opiate use disorder on treatment with buprenorphine/naloxone 8/2 mg 2 times a day (BID) who was followed in an outpatient general psychiatry clinic that specializes in patients with co-occurring substance use disorders. Although maintaining sobriety from opioids, the patient continued to struggle with acute on chronic pain secondary to osteoarthritis that had left him walking with a cane. The patient was started on tramadol 50 mg 3 times a day (TID) for acute pain by his primary care physician (PCP) while he awaited surgical intervention. He reported analgesic effect with buprenorphine/naloxone but noted that it did not last the full period between his doses. He reported further improvement in his pain along with greater daily functioning with the additional use of tramadol, without side effects or withdrawal symptoms. Discussion: Current recommendations for pain management in patients on BT include discontinuation of BT therapy and/or addition of an adjunctive opioid analgesic (including additional buprenorphine/naloxone) while continuing agonist medication for treatment of opioid use disorder. However, determining which medication to use can be difficult, as there has been no literature examining this issue. In this case, the combination of buprenorphine and tramadol demonstrated an additive analgesic effect. Randomized control studies need to be performed to further understand the changes in pain measurement in patients on BT with tramadol compared with other adjunctive analgesic medications.

Keywords:

• Additive analgesia
• analgesia
• buprenorphine
• opioid use disorder
• pain
• suboxone
• tramadol

Acknowledgments

The authors thank Christina Borba, PhD, who was instrumental in coordinating the development of the manuscript while also suggesting edits and providing feedback throughout the process of writing the manuscript; and Kelsey Johnson, who was a critical component in helping to properly illustrate the poster based off of this case report. This poster was presented at the IPS Mental Health Conference in 2016 in Washington, DC.

Additional information

Notes on contributors

Cristina Montalvo

Cristina Montalvo, Nicolas Genovese, and John Renner, contributed to the conceptualization, writing and editing of this manuscript. Nicolas Genovese was responsible for crafting the majority of the manuscript and performing the necessary literature search to do so. Additionally, he created the framework for the poster, which is available as supplemental material, as well as presenting that poster at the IPS Mental Health Conference in 2016. Cristina Montalvo was the physician who originally treated the patient featured in this case report. She performed the preliminary literature search, crafted the case portion of the manuscript, and oversaw the development of the remainder of the manuscript and poster. John Renner provided the final edits for both the manuscript and poster to ensure that they were ready for publication and presentation, respectively.

Nicolas Genovese

Cristina Montalvo, Nicolas Genovese, and John Renner, contributed to the conceptualization, writing and editing of this manuscript. Nicolas Genovese was responsible for crafting the majority of the manuscript and performing the necessary literature search to do so. Additionally, he created the framework for the poster, which is available as supplemental material, as well as presenting that poster at the IPS Mental Health Conference in 2016. Cristina Montalvo was the physician who originally treated the patient featured in this case report. She performed the preliminary literature search, crafted the case portion of the manuscript, and oversaw the development of the remainder of the manuscript and poster. John Renner provided the final edits for both the manuscript and poster to ensure that they were ready for publication and presentation, respectively.

John Renner

Cristina Montalvo, Nicolas Genovese, and John Renner, contributed to the conceptualization, writing and editing of this manuscript. Nicolas Genovese was responsible for crafting the majority of the manuscript and performing the necessary literature search to do so. Additionally, he created the framework for the poster, which is available as supplemental material, as well as presenting that poster at the IPS Mental Health Conference in 2016. Cristina Montalvo was the physician who originally treated the patient featured in this case report. She performed the preliminary literature search, crafted the case portion of the manuscript, and oversaw the development of the remainder of the manuscript and poster. John Renner provided the final edits for both the manuscript and poster to ensure that they were ready for publication and presentation, respectively.